On October 10, history was made with the
announcement of the newest hepatitis C medication, Harvoni. Gilead
Sciences’ pill contains two drugs, sofosbuvir (Sovaldi) and ledipasvir.
Harvoni is approved for the treatment of genotype 1, hepatitis C virus
(HCV) infection. Cure rates range from 94 to 99%. Treatment is
typically 12 weeks, although 40% of patients may need only 8 weeks of
treatment; patients with cirrhosis who failed prior treatment will need
24 weeks. Harvoni has a few mild side effects; fatigue and headache are
the most common.

However, a war is raging,
ignited when Gilead slapped a $1000 per pill price tag on to its first
HCV drug, Sovaldi. Twelve weeks of Sovaldi costs $84,000, but since
Sovaldi is given with at least one other drug, the costs are much
higher. Gilead’s new drug, Harvoni costs more at $94,000, $63,000 for 8
weeks, and $188,000 for 24 weeks of treatment with this $1,125 daily
pill. These prices are driving state Medicaid programs and some
insurance companies to push back by instituting stringent
pre-authorization regulations. For example, some states force patients
to qualify for HCV treatment by proving they have cirrhosis.

HCV patients are the victims in
this war. I believe that this victimization is partly caused by stigma.
HCV’s association with drug use doesn’t win us any sympathy. Although
it appears that healthcare is abandoning HCV patients, few are more
ignored than people with HCV who are in jails and prisons. However, the
incarcerated were not ignored by the American Association for the
Study of Liver Diseases and the Infectious Diseases Society of America,
who assigned a high treatment priority to the incarcerated. (For more
information, see Recommendations for Testing, Managing, and Treating Hepatitis C provided under Resources.)

This month’s article addresses
the issue of HCV in prisons, and discusses the pros and cons of
treating the incarcerated, especially in the light of the cost of
treatment. With little data about HCV in jails, the discussion is
limited to HCV in U.S. prisons.

The Reality of Incarcerated Persons with HCV
HCV prevalence in the U.S. is determined by data
collected from the National Health and Nutrition Examination Survey.
Since this household survey only sampled non-institutionalized people,
we don’t know how many incarcerated people have HCV. The Centers for
Disease Control and Prevention (CDC) estimates that of the 2.2 million
people in U.S. jails and prisons, 30% have hepatitis C. Other estimates
are between 17% and 60%. Compared to the prevalence of HCV in the
general population (1.6%), HCV rates in prisons and jails are high.

Arguments in Favor of Offering HCV Treatment to the Incarcerated
Since more than 90% of those in prison will be
released, treating the incarcerated is good for all of us. The HCV
Guidelines state, “Persons who have successfully achieved an SVR
(virologic cure) no longer transmit the virus to others…successful
treatment benefits public health.” With such a high
density of HCV+ people, prisons seem like an excellent
place to offer treatment.

Furthermore, with a 1% acute
HCV infection rate in prisons, it is also good for others in prison.
With high-risk behaviors such as injection drug use, tattooing, men
having sex with men, violence, and sharing of personal care items, it
is surprising that the acute HCV rate isn’t higher. However, it may be
higher, since HCV is not well-tracked in prison.

Various state prison systems
see the logic in treating HCV in this at-risk population. Illinois and
Iowa made national news when they approved Sovaldi to treat HCV
patients. Other states are considering this, while some have clearly
rejected the idea.

From a medical standpoint, it
makes sense to treat HCV in prisons. Healthcare delivery is always the
right thing to do. It is never OK to turn our backs on anyone who needs
medical care.

Arguments Opposing HCV Treatment for the Incarcerated
Medically, there are no reasons to withhold HCV
treatment in prisons. The new drugs are easier to tolerate, lifting the
decades-old concern about the neuropsychiatric side effects that
accompanied ribavirin and interferon.

One could argue that the cost
of Harvoni makes treatment prohibitive. The problem with this argument
is that if we don’t treat HCV early, we may face more serious and
expensive problems. Cirrhosis, liver cancer, and transplantation cost
far more than treating HCV in its early stages. This just pushes the
problem down the line, leaving someone to have to pay for the patient’s
medical care, whether that patient is incarcerated or released.
Moreover, even if you are able to cure HCV in a cirrhotic patient, you
still have a patient with a serious liver disease, so the system gains
little by only treating cirrhotics.

There is also the argument that
patients who are cured may become re-infected with HCV, and you have
wasted money treating them. That is like saying that someone in a knife
fight might get stabbed again, so we shouldn’t stitch the wound. It
sounds crazy, but isn’t that what we are saying?

Caring for the sick is always
the right thing to do. Withholding healthcare is inhumane and immoral.
No one is excluded from the Hippocratic Oath. “With regard to healing
the sick…I will take care that they suffer no hurt or damage.”